Early Detection of Learning Disability - EDLD

IAP Presidential Action Plan 2019

Department of Education
Department of Puplic Heath and Preventive Medicine
Government of Tamilnadu
NRHM

Dyslexia TOT for Teachers

Module

Organized By
Indian Academy of Pediatrics (National)
IAP Tamil Nadu State Chapter
IAP Cuddalore District Branch
Project Co-ordinator
Dr. V. SIVAPRAKASAM, MD., DCH., PGDN., FIAP., PGD-AP
National Trainer for LD Dyslexia in Particular
National EB Member of IAP 2014, 2015, 2017
President IAP TN 2012
Nataraja Children’s Hospital & Child Development Center
 Early Detection of Learning Disability-EDLD
IAP Presidential Action Plan 2019
Dyslexia TOT for Teachers
Why this Training programme for Teachers
Dyslexia a learning Disability gains importance in the present Scenario.
1. Dyslexia needs to be diagnosed at the age of 7.
2. DSM 5 Criteria made very easy for a Paediatrician to identify Dyslexia Tamilnadu
Dyslexia Diagnostic Tool TDDT Designed in the year 2012 by Tamilanadu
IAP, which is now validated Tamilnadu Dyslexia Check List.
3. LD is included in the Disability act and the Government is ready to provide
remedial Teachers to the Schools to provide Free Remedial teaching to the
poor Children under RBSK Scheme funded by NRHM.
4. It is the need of the hour to identify the Children with learning Disability by
Training of Teachers to identify Leaning Disability.
5. The incidence is nearly 5 -10 % In Tamilnadu there are 1.3 Lakhs of children
to be identified.
6. There are very minimal number of Child Psychiatrist in our country to
Diagnose Dyslexia. So if we Train our Paediatricians in IAP we will be able to
identify almost all children with this Problem with in 2025.
7. Since their IQ is more than 100 up to 140 with Remedial measures they will
overcome the problem and come up in life with little help.
8. Though they are poor in Academic intelligence they possess any one of the
Multiple Intelligence and so when they are given support they may become
very big people.
9. Paediatrician can also identify the At-Risk children who may be diagnosed as
Dyslexia at the age of 7, at very early age and can provide early intervention.
10. We have a dream to identify all the children with Dyslexia in our Nation and
to Provide Remedial teaching with in a time limit of 2025 – Vision 2025.
Dr. V. SIVAPRAKASAM, MD., DCH., PGDN., FIAP., PGD-AP
National Trainer for LD Dyslexia in Particular
National EB Member of IAP 2014, 2015, 2017
President IAP TN 2012
Consultant Developmental Paediatrician SLIMS, Pondicherry
Nataraja Child Development Centre & Nataraja Children’s Hospital
127, S.P. Koil Street, Chidambaram - 608 001.
Mail : vsiva_pr@yahoo.co.in Cell : 98430 29768

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 DYSLEXIA INTRODUCTION
No child wantonly fails in a class.
An Intelligent Child who fails a class.
Normal or High normal IQ 100 - 140.
Who answers well in oral but fails in written test.
Reads slowly word by word, hates reading, loses places.
Poor hand-writing,
With lot of Grammar and spelling mistakes.
Reversal tendency was as saw 17 as 71.
Poor in maths - We suspect Dyslexia - SLD.
Language
Children acquire language naturally in a sequence.
• Listening • Speaking
• Reading • Writing
Listening
• Hearing should be normal.
• Hear the sound of the word ball.
• Attend to individual speech sounds - b a l l.
• Record in the memory.
• Associate with the meaning.
• Retrieval of known word when needed.
Speaking
• Repeats the mothers words. • Use the muscles of articulation.
• Recollect from memory. • Nose & vocal cord.
• Relate the meaning of the word. • Speech centre is in temporal lobe.
• Use it when needed.
Seeing
• Seeing on object. • Store in the memory –occipital lobe.
• Vision – normal. • Refractory error to be corrected.
• Relate to the ball from the visual memory.
Reading
• Two-way process involving both. • Understanding its meaning.
• Recognition of a word. • Five stages – in carillo’s reading cone.

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Stage 1 - Pre Reading Skills
• Learn to discriminate shape, size, and colors.
• Visual - Tracking from left to right.
• Eye hand motor coordination.
• Fallowing instructions and directions.
• Listening skills.
• Problem in matching size and shape.
• Difficult to distinguish sound loud & soft.
Stage 2 - Initial Reading
• Learning letter sound association using picture clues.
• Building a basic sight word vocabulary.
• Ball.
• Attempts to Analyze words and reads with confidence.
Rapid Development of Reading Skills
• Silent reading • Begins to read for Pleasure
• Fluency • Acquire a basic grounding in reading habits.
• Ease in oral reading
Stage 4 - Wide Reading
• Expanded vocabulary • Comprehension • Read independently
Stage 5 - Refinement
• Able to draw inferences & conclusions.
• Critically evaluate reading material.
Reading
• Attention • Discrimination • Perception
• Memory • Conceptualization • Evaluation
Reading is a two way process.
• Decoding- Learning to associate Symbols with sounds.
• Learning the meaning of words.
Writing
• Is a complex skill need several abilities.
• Keeping an idea in mind.
• Ordering of idea in sequence & relationship.
• Planning and designing for the correct placement of words & ideas.
• Selection & utilization of letters for words.
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Learning
How children process information.
How they take information in (input);
How they understand it, memorize it and organize it in their mind (cognitive
processing).
How they demonstrate ,that they know this information (output).
Language
Language is system of verbal symbol used for human communication.
Language has got 5 Components.
Components are
– Phonology – Semantics
– Morphology – Pragmatics
– Syntax
Phonology
Phoneme is the smallest linguist unit of speech that signals a different sound
[distinct speech sound] p, b are phoneme.
Phonics is the method of teaching reading by attending to sound units of letters.
Difficulty with connecting the shape, sound and the name of the Letter.
Morphology
Morphology is the study of word formation.
Morpheme is the smallest linguist unit with meaning.
It may be prefix suffix, or root word - dogs, dog + s 2 morphomes.
Looks at grammatical marker. Ed, ing, persons – s.
Syntax
Syntax is the rule system that governs the structure of a sentence.
It specifies word order Ball the man hit
The ball hit the man Problem in syntax face problem in comprehension.
Somantics
Somantics is the ability to obtain meaning from the words sentences and other
word combinations. Helps to participate in meaningful conversation.
Pragmatics
Pragmatics is the use of language in social contexts.

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 Dyslexia,
History of Learning Problem,
Difficulty to read, write, do maths, spelling, hand writing, memory.
F/H/O Dyslexia – father, mother, sibling, grand parents.
H/O consanguinity
AN – Problems PET, HT, GDM, APH, ’ FM.
Natal: LSCS, Forceps, Birth Asphyxia, Delayed 2nd Stage, MSAF.
Post Natal; Hypo-glycemia, Jaundice, NEC, neonatal convulsions neonatal
infections.
Delayed Speech,
Missing of the crawling stage,
Delayed mile stones.
DOC - Development Observation Card
Social smile - 2 months Sit alone - 8 months
Head holding - 4 months Stand alone - 12 months
Make sure the baby can see, hear and listen.
Case scenario
Malathi, Age 13, Thrown out of a convent School – Not completing the home
work daily. Stairs at teachers without answering. Accepts punishment without
showing any improvement in reading or writing.
Persistent low marks. Very good in singing & dancing.
She cried for the punishment. On examination perfectly normal.
Sweet girl with love & affection. Unable to read even 4th std book.
Very intelligent also Uunable to write simple dictation words.
IQ - 120% Reading level 4th
Writing level 3rd sent for Remedial teaching.
Admitted in Government School Improved in studies and able to get reasonable
marks. In 10th std got government concessions. Now got B.Com & MBA
degree Got selected in campus and placed in a good job. We identified
several children like her at that time and all got PG degree & well placed.
Specific Learning Disability
SpLD is a group of neuro - developmental disorder manifesting as persistent
difficulty in learning to efficiently read (dyslexia), write (dysgraphia) and perform
mathematical calculations (dyscalculia) despite normal intelligence conventional
schooling, intact hearing and vision, adequate motivation and socio-cultural
opportunity.

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 DYS = TROUBLE LEXIA = WORDS
TROUBLE WITH WORDS
“A disorder in one or more of the basic psychological process involved in
understanding or using spoken or written language, which may manifest”.
ƒ READING - DYSLEXIA
ƒ WRITING
ƒ MATHEMATICS
- DYSGRAPHIYA
- DYSCALCULIA
} SLD

ƒ ORAL (SPOKEN) - DYSPHASIA

ƒ MOTOR INCOORDINATION - DYSPRAXIA
}CO-MORBID
Check List .R/O Other Conditions
1. Vision Normal.
2. Hearing Normal.
3. No medical Problem : CRF, Asthma, CCF, Hypothyroidism.
4. No Psychological Problem. 8. No Autism Spectrum Disorder.
5. No mental Retardation. 9. Normal Home Environment.
6. Not a Slow learner. 10. Normal School Environment.
7. No ADHD. 11. Confirm. Specific Learning Disability.
Medical Factors
ƒ Vision ƒ Hearing ƒ Speech
Medical Problems
Epilepsy and its treatment Hypothyroidism
Chronic illnesses - CRF, CCF, Asthma, Prematurity & LBW
Vision : Yes No
1. Is he able to read the letters from Blackboard?
2. Is he able to read the letters from Note Book?
3. Is he able to read from the Chart?
4. Is there any congenital cataract ?
Hearing:
1. Is he able to turn towards sound when his name is called?
2. Is he able to hear the whispering words?

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 3. Is he able to respond to oral orders?
E.g.: lift your right hand.
4. Is there any wax or Ear Discharge ?
Mental retardation
IQ <70
Recognized before 1st year.
Varying degree of impairment in Language development.
Short term memory deficit.
low attention span.
Behavioral problems.
Delayed milestones.
ADHD
Inattention : Not listening to the Teacher but looking elsewhere, being in his
own world.
Hyperactivity : Moving about all the time like a key driven toy without sitting in
a place for a while.
Impulsivity : Answering over promptly even before completing a question.
Slow learners
IQ 70 to 89 Poor Language &communication skills.
Poor reasoning ability. Lack of academic success.
Short attention span. Low power of retention & memory.
Poor retention. Anxiety & fear of failure poor self concept.
poor motivation and work habits. School phobia
Emotional problems
Anxiety Oppositional defiant Disorder
Depression Conduct Disorder
Home environment
Deprived, discordant, un stimulating home.
Lack of adequate facilities for studying.
Lack of encouragement for studying and lack of role models.
Parental illiteracy, poor reading and TV viewing habits.
Significant life events.

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 Child abuse.
Single parent, separated parents.
Alcoholic, workaholic parents.
School environment
Recent change of school / medium of teaching,
Over expectation
Parents
Teachers
Poor / inadequate teaching methods.
Overcrowded classrooms.
inRote based learning methods and poor study skills.
Teacher insensitivity to problems of children with poor scholastic performance.
DSM.5-Diagnostic Criteria-SLD
A. Any one of the following symptoms that have persisted for at least 6 months,
1. Inaccurate or slow and effortful word reading.
2. Difficulty in understanding the meaning of what is read.
3. Difficulties with spelling (e.g., may add, omit, or substitute letters)
4. Difficulties with written expression (e.g., makes multiple grammatical or
punctuation errors within sentences.
5. Difficulties in mastering number sense (Maths).
6. Difficulties with mathematical reasoning.
B. 2 grade low for the age
C. Onset before 7 years
D. Rule out other causes
Early signs of Dyslexia
Missing of the crawling stage. Difficulty in tying the shoe lace.
Speech delay. Difficulty with Rhymes.
Difficulty in buttoning the shirt. Difficulty with puzzle.
Management Principals
1. Remedial Education – Special educator – Educational assessment, IEP.
2. Occupational therapy – eg handwriting skills.
3. Speech and language pathologist.

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4. Counselling and Guidance to family – psychologist/counsellor.
5. Treatment of Associated Problems – General paediatrician, Developmental
paediatrician, Psychiatrist.
6. Career counselling – school along with parents.
Periodic review for Improvement.
Remedial Teaching
When a child is not able to understand in a way we are Teaching we will
change the way of teaching so that the child will understand.
It is Costly Rs. 600-800 per hr.
What is Remedial Education?
• A specific method of instruction/teaching.
• Based on specific deficits in performance of child.
• Starts after collecting relevant information about the child’s performance.
• Develops on the strengths.
• Fills in the gaps in learning.
• Enables child to achieve academic skills.
Principles
• The program is started at the level the child has already achieved.
• The program should proceed at a pace comfortable for the child.
• Each stage is given a lot practice and drills.
• As much as possible, these instructions should be given in the form of games,
puzzles and in forms enjoyable and motivating for the child.
• The intervention should happen as early in primary school as possible (6 - 8 yr
of age) so that when the child reaches middle school or secondary school,
more advanced reading, comprehension and study skills can be developed.
• One-to-one basis in a child friendly environment.
• Minimum one hour duration.
• Two to three sessions per week.
• R.E. should continue all the year round and not only during vacations or
schooldays. However, the sessions could be intensified during the vacation.
• R.E. is not equivalent to giving tuitions but done by special educators or by
the teachers specially trained in remedial education.
• R.E. has to be given in addition to regular school work.
• R.E. should be continued throughout school life.

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Remedial Programme
• IEP (Individualized Educational Plan).
- Assessment based.
- Structured plan.
• Statement of child’s present level of performance.
• Statement of annual goals & short term objectives.
• Nature of services.
• Criteria for evaluation of educational goals.
Referral when needed
When the problem is more, needs Special School.
Send for Assessment in Special centre.
Special School for Dyslexic Children in Delhi.
ADHD to be treated before Remedial Teaching.
Counselling of Parents
Spend some time to tell about Dyslexia.
Clear their doubts.
Bring down their Anxiety.
Help them to get Remedial Teaching.
Guarantee them he will become a big person.
Parents should know
Neuro Developmental & Biological.
Involves Brain circuits, EEG, MRI, CT not needed.
Not a disease or illness, No drugs needed.
Usually genetic – child is not responsible.
Early intervention – remedial Teaching works well.
Know the weakness and Strength.
Poor Self-esteem, inferiority complex.
Don’ts- compare, rude words, beating.
Don’t discuss about him, Learn how to help.
Psychological Support for the Psychological effects
School refusal, School failure. drop out.
Depression, Anxiety, Suicidal attempts.

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 Intolerance and Anger, Run away. Inferiority complex, Poor Socialisation.
Lack of self confidence. Dejected, Child Vs Parents.
Emotional instability. Loss of self esteem.
Counselling of Children
Tell them –they have a problem and it is not their fault.
Motivate them to overcome the Problem.
They need to spend more time and work hard.
Counsel them not to worry and they will be alright.
Prize them &reward for small achievements.
Government Concessions
One Hr. Extra time in Public Exams.
No mark reduction for Grammar and Spelling Mistakes.
Can use Calculator in Maths Exam.
Exemption from writing one Language.
Can use Scribe.
Help to get Government Concessions.
Needs a certificate from Child Psychiatrist or Developmental Paediatrician.
Assessment by Clinical Psychologist.
Letter from HM and Parent, student.
District Level Committee is there in District Head Quarters Hospital.
Need to Apply through School to the Director of School Education.
Inclusive Education & resource Room
Every School should have Resource Room.
Training of Attention, Concentration, Correction of Spelling and Grammar
mistakes should be done in the regular school.
Children will attend regular School along with Remedial Teaching in the
Resource Room.
Team of Remedial Teacher, Counsellor, Occupational Therapist & Speech
therapist is ideal in resource room.
Number in Tamilnadu.
Number of Children in the Schools ——— 1.35 Crores
Number of Teachers working in the Schools ——— 4.75 Lakhs
Probable number of Children with Dyslexia ——— 13.5 Lakhs

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Why
Load is very High -10% of Students (13.5 lakhs).
Identify at the age 7 will be Ideal.
IQ is 100 to 140.
Remedial teaching works well.
Facts about Multiple Intelligence.
Children are suffering by heart.
- hurt by Teachers, Parents, Friends in spite of the fact they are not at fault.
Hidden tragedy - unlike Typhoid, Encephalitis.
Unable to cope up with the Educational Pressure, Parental Pressure. Peer Pressure.
One child –Major Psychotic illness Schizophrenia
With little help they will blossom well .
Additional Screening and recording for Reading Disorder
Observations Interviews Questionnaires
We need to assess the Reading problem in detail.
Current attitude towards reading.
Reading habits and interests.
Attention capabilities.
Incentives used.
Demands & opportunities provided.
Environmental response.
Mannerism-rapid, head movement, sub vocalisation.
Appropriate way to collect information.
Direct Assessment
Specific strategies employed in reading.
Self monitoring process - make sense.
Extent of comprehension from oral & silent reading.
Difference between spontaneously recalled details reasoning &inferences
compared to evoked by prompts.
Level of automaticity – words, phrases Unknown words – how recorded.
Formal Assessment
Diagnostic reading scales.
Durrell annalisis of reading difficulty.
Gray oral reading test,Woodcock reading mastery test.
Informal reading inventory.

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 READING ASSESSMENT CHECK LIST
Type of
No. 1st check 2nd 3rd Common difficulties encountered
reading
1 Word byword reading
2 Incorrect phrasing
3 Poor pronunciation
4 Omission
5 Repetition
6 Inversion or reversal
7 Insertions
8 Substitutions
9 Basic sight word not known
10 Sight vocabulary not up to grade level
11 Guesses at work
12 Consonant sounds not known
13 Vowel sound not known
14 Blending not known
15 Lacks desirable structural analysis
16 Unable to use context clues
17 Contractions not known
18 Fails to comprehend
19 Unaided recall scanty
20 Response poorly organized
21 Low rate of speed
22 High rate of expense accuracy
23 Voicing lip movement
24 Inability to skim
25 Inability to adjust reading rate of
difficult material
26 Written recall limited by spelling ability
27 Undeveloped dictionary skill
28 Inability to locate information

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Sample - IRI
Magic doors. 4 or 5 comprehension questions.
Graded passage of 100 words. Recollection of specific details.
Ask the student to read. While reading note the errors.
Suryas mother asked him to go to the big new store at the corner. His little
brother Raja said,’I want to go too! I will be good’ So Surya took his little
brother to the big new store.
There were two big doors. One door had the word IN on it.The other door had
the word OUT. Surya and Raja went to the IN door.
Whish! The door opened all by itself! Raja said ‘look at that ! It is Magic !’
‘You are silly!’ said Surya, ‘it is not magic, the new door works by electricity’
Magic Doors - Comprehension Questions
Who went some where? (Surya & Raja).
Why did they go? (mother asked them).
Where did they go? (new store at the corner).
What was written on the door? (IN & OUT).
What seems like magic?(door opening by itself).
What was the magic really? (electricity).
Recording System of Oral Reading Errors
Mispronunciation Went [Want]
Substitution Want – [Went]
Refusal to pronounce TP - No Attempt [Went]
Insertion Sent [on] To
Omission To [The] School
Repetition In The little house
reversal That he saw [he]
The Cloze Technique
To evaluate comprehension skills.
Unfamiliar passage every 5th word is omitted as blank.
Reader is to supply the missing word.
Easier &quicker, Less expertise.
Group administered.
Good measurements of semantic & syntactic cues’ over 8 years.

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The Cloze Technique
Robinson Crusoe looked out to sea, yes there was a ———— [ship] coming.
Robinson Crusoe ran ———— [down] to the beach], calling ————
[and] waving as he went. ——— [He] lit his fire to ——— [signal] the ship.
The captain————— [saw] the signal and stopped ——— (the) ship
Regular Questions -Put in a Board
How he/she performs in School?
What is his/her marks in last exam?
Is there any problem in reading? Writing or Maths?
Does he/she read slowly, word by word, skip words, skips sentences, read
again and again, loses places?
Does he/she finishes home work in time?
Is there lot of Spelling Mistakes or Grammar mistakes ?
Is there Poor Hand writing?
Is there any reversal tendency? Was- saw, 17-71, b-d
SPELLING TEST ( Schonell’s list)
Class I Class II Class III Class IV Class V
Cat Jug Drank Strike Crime
No Get Swing Hobby Risky
Red Sip Sheep Swimming Address
And Drop Bath Folded Hero
The Clip Train Sailor Movies
It Sing Catch Tight Expect
We Thank Child Climb Studying
Like Boat Jump Listen Business
Play Care Walk Study Distress
Here Father Uncle Carrying Trouble
Pig Down Light Foolish Quite
Dog Said Lake Dancing Lovely
Was Mother Stick Picture Killed
You Ask Short Chair Knowledge
Yes Shop Tall Table Eating

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 L D. SCREENING CHECK-LIST - FOR TEACHERS
Sl.No. Statements Never Sometimes Frequent
1 Reads slowly, word by word – difficulty in reading
/ skip words,0r Sentences
Makes Mistakes in reading like omits Substitutes words
add words or
Guess work in reading
not understanding what he read
2 Can answer questions orally but has difficulty in writing answer \
oral work is better than written work
3 Writes or reads figures or letters in wrong way eg.17 for 71, 6 for
9, b for d, was as saw (reversal tendency)
4 Difficulty in differentiating letter sounds for vowels and blends
e for l, ch for sh.
5 Difficulty in rhyming words and repeating them
6 Difficulty taking notes or copying from black board and books
7 Confusion with math’s symbols [+,-,x] Difficulty in addition,
subtraction, multiplication and Division
8 Difficulty in spellings. Lot of Spelling mistakes & grammar mistakes
9 Difficulties with spatial orientation and direction eg. Confusion
between left and right, east and west, up and down
10 Misplaces upper and lower cases letters, e.g. Be TTer , n for N
3 or more Points positive in frequent category = Positive Screen
5 or more Points positive in sometimes category = Positive Screen
Person filling the checklist should have observed the child’s academic performance for a minimum period of 6
months.(teachers, parents and other Professionals)
Other Problems Yes No
1. Is there any visual problem?
2. Is there any hearing probelm?
3. Is there any Medical problem? or Medication?
4. Is there any Psychological problems? Persistent sad mood
(Depression) Anxiety Excessive anger
5. Is there any problem of ADHD? Does the child sit in one place for
more than 3mts? Forget things, runs like a key driven toy? Not
listening to the Teachers ? , Answering impulsively even before
Teacher completing the questions ? ( ADHD)
6. Is ther any problem of ASD? Lack of eye to eye contact,
solitary play not responing to sounds?
7. Is there any problem of Intelectual disability (MR)?
8. Poor memory

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Parents Questinire
Name Reg.No.
Age & Sex Address
School Name
Class
Father’s name
Father’s cell number

History
What are the parents concerns? Yes No
Repeated Failure in any subject or class?
Problems in reading writing, doing maths ?
Reading slowly word by word, missing letters, words,
Is there very low marks ?
Mirror image Writing, & Reading was- saw,17-71
Is there lot of grammar and spelling mistakes?
Poor handwriting, writing slowly
Is there Poor memory Visual/auditory ?
Is there hyperactivity, always on a move as a key driven toy, not able to sit in a place,
not attentive in class, Bursting out answers before completing the questions?
Does he in sad mood for more than 2 weeks?
Any communication problem - lack of eye to eye contact?
Any other problem - Specify
F/H/O Dyslexia –father, mother, sibling, grand parents
H/O consanguinity
Socio economic Status: monthly income in thousands Rs. below 5, 5-10, 10 - 20 20-40, 40+
Education of the father Nil, 10 ,+2 ,UG,PG, professional
th

Education of the mother,Nil,10th +2,UG,PG, professional

Occupation; Professional , semi professional , clerical or shop worker-skilled ,
unskilled , unemployed
Any family pathology? –Alcohol, Interpersonal, Drugs
Nature of the School – Private Government Aided
Syllabus – State, CBSC, IGCSC, ICSC
AN –Problems :excess vomiting , sugar , high blood pressure , low Hb.
(Anaemia), Swelling of the feet.
Natal: , Not Cried, Breathing difficulty, Preterm, low birth weight Meconium aspiration
Nature of Delivery: :Normal, operation, Forceps,
Post Natal;, Fits Fever , unconscious, , Jaundice , Not feeding well,
Intensive care given in NICU
Any problem in the Ist 2 years of life? (Hospital admissions - fever with fits, altered sensorium)
Any H/O Chronic illness like Asthma, Recurrent fever , heart problem , Kidney problem ,
poor Brain development
Any continuous Medication given to the child ?
Write the month of acquiring the milestone
Social smile , head control , crawling sitting standing Speech, 2 words,\
mummy, Daddy

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